Fabrication of a Maxillofacial Prosthesis with a Novel Suspension Technique for a Patient with Exenteration: A Case Report

A 70-year-old man referred to our cosmetic prosthetics center in Tehran, Iran. The patient had a massive infection in his left eye that spread into the frontal and maxillary sinuses. Therefore, the patient had undergone a radical excision procedure for orbital exenteration as well as a conservative excision to remove the superomedial region of the frontal sinus and inferomedial part of the maxillary sinus (Figure 1). Therefore, the frontal and maxillary sinuses and the nasal cavity were exposed as a result. The patient suffered from severe depression after this experience, which had made him reluctant to communicate and socialize with others.

In the process of prosthesis fabrication, we first covered the damaged area with Vaseline gas and took a negative impression from his entire face (Figure 2). The hardened negative impression was filled with liquid dental stone (Welmix, GC Fujirock, Leuven, Belgium) and left to dry out to provide a working positive cast.

An ocular prosthesis was fitted on this working positive cast to ensure that it is positioned correctly (Figure 3). The skin of the missing parts of the face was also mirrored with the opposite side(9). We made a silicone prosthesis and attached it to the patient’s face with a special adhesive (Figure 4). However, there was a problem with an adhesive suspension due to the vastness of the damaged area and the nasal cavity’s connection to the back of the prosthesis. Accordingly, with each deep exhalation, the air flew to the back of the prosthesis and caused it to detach from the patient’s face. We also tried using glasses to help with the suspension, but it failed.

Therefore, we decided to design a prosthesis that

had internal and external components with an adequate suspension (Figure5). The internal part, which was in contact with the mucosal tissue, was made of heat-cured acrylic resin. The ocular prosthesis was placed on the external part which  was made of flexible silicone. The internal rigid socket was connected to the external part using an anchor mechanism.

In the fabrication of the prosthesis, we covered the sinuses and nasal cavity with Vaseline gas and then re-molded the lesion site. After a suitable negative template of the patient’s face was obtained, we made a positive cast and modified it. In this new positive working cast, a bony lock was created using the anatomic undercuts to increase prosthesis suspension and provide rotational stability. Subsequently, a 1.5 mm thick shell of heat-cured acrylic resin was made based on the anatomy of the

entire cavity floor.

After the shell was polished, it was tested on the face cavity floor of the patient, ensuring airway closure, fitting, convenience, and proper suspension. Afterward, we vertically attached an acrylic rod (8 mm in diameter) to the shell bottom (Figure 6). This rod had a handle for the shell to be placed on the patient’s face, and it acted as an interface for attaching the external silicone to the internal parts of the prosthesis (due to its elastic properties, silicone was placed firmly around the acrylic rod like a pen cap) and facilitated the process of donning and doffing for the patient.

We attached the external silicone component of the prosthesis after attaching the rod to the shell and inserting it into the patient’s face cavity. The external

Fabrication of a prosthesis for patients who have lost an eye and parts of their cheekbones and nasal tissues is a challenge. The prosthesis aims to cover the open cavity after the surgery and improve the patient’s appearance, psychosocial status, and quality of life(3). The advantages of anatomic suspensions used for placing the prosthesis in this case included proper placement, elimination of the patient’s respiratory problem, and easy use (donning and doffing). The patient could do various activities after putting on the prosthesis (i.e. bending, stretching, eating, talking, and smiling) without the risk of falling or loosening.

A problem with silicone materials that are in contact with mucous tissue is the creation of an environment for germs and fungi growth (10) and the

Figure 7. The final prosthesis.

risk of infection. In our case, we used acrylic resin to build an interior conformer to minimize the probability of growth of these microorganisms. In addition, due to the vastness of the affected area, the patient needed to put on his prosthesis with a special maneuver (rotating the internal acrylic conformer over the lesion area). Therefore, placing a rod on the acrylic conformer facilitated this maneuver. The other benefit included the easy connection of the prosthesis’ internal acrylic part to the external silicone part, which eliminated the need for adhesives to connect the internal and external parts of the prosthesis.